Voters Want Affordable Meds. Legislatures Are On It.

Health care affordability is a top issue among voters, with over half worrying they won't be able to pay for their medications, according to a recent KFF poll. Lawmakers addressed the issue this session with a variety of policy approaches to increase state and patient access to affordable prescription drugs.

More than 535 bills in 46 states, Washington, D.C., and the territories are being tracked in NCSL's Prescription Drug Legislation Database. As of September, 33 states have enacted at least 83 bills.

Here are some of the prescription drug policy trends identified during this year's legislative sessions.

Coverage

Health insurers and the pharmacy benefit firms they contract with use various mechanisms to manage the amount and mix of drugs covered under a benefit. States may impose or ease restrictions on these tools within state-regulated plans. At least 31 states explored related policy options.

Quickly gaining national attention: a class of medications called GLP-1 drugs, or glucagon-like peptide-1 receptor agonists. The medications are used primarily in the treatment of Type 2 diabetes and, in some cases, obesity, as they've been found to aid in weight loss. At an average annual list price of almost $12,000 per person annually, some health plans do not cover the drugs or are restricting coverage, leaving it out of reach for many who must pay out of pocket.

At least a dozen states pursued legislation addressing the coverage of GLP-1 drugs in 2024. As more of these products come to market and are available for more indications, and as awareness of them grows, state lawmakers face the policy implications of balancing access and affordability.

Earlier this year, North Carolina's state employee health plan stopped coverage in cases where obesity is the listed indication. In contrast, enrollees in the Illinois state employee group insurance program now have access to these treatments starting July 1. (Learn more about GLP-1 access and affordability in this upcoming Our American States podcast, available Sept. 15.)

Prices

In mid-August, the federal government published the negotiated prices of the 10 Medicare Part D drugs subject to the federal Inflation Reduction Act of 2022, or IRA.

Before the IRA, nine states had established prescription drug affordability boards, or PDABs, which in some instances have the authority to conduct reviews of certain high-cost drugs and establish upper payment limits paid by state purchasers. Eight states considered PDABs during the 2024 legislative session; however, none has enacted legislation so far.

With at least five cost reviews completed, Colorado's PDAB is one of the furthest along in its work. New legislation requires the board to consider as part of a cost review whether a drug has an approved orphan drug designation for one or more rare diseases. The board must also hear from consumers and the Colorado Rare Disease Advisory Council.

Vermont will hire two new board positions within the existing Green Mountain Care Board to create a program regulating prescription drug costs in the state. The new analysts will develop a framework and methodology to look at the impacts of the eventual federal maximum fair price established from the IRA, the experiences of states that have developed PDABs, and other promising state strategies.

Seven states approved importation legislation in attempts to address high drug prices before 2024. To help legislators better understand this issue, NCSL hosted a webinar earlier this spring. Dr. Aaron Kesselheim from Harvard's Program on Regulation, Therapeutics and Law provided an overview of the federal and state landscape, and importation program directors Kelly Swartzendruber and Devona Pickle from Colorado and Florida, respectively, gave attendees exclusive insight into the status of the programs in their states. Eight states considered importation legislation this year, with Virginia passing a bill to establish a work group to study best practices in other states.

Pharmacy Benefit Managers

Policymakers have kept a pulse on the business practices of pharmacy benefit managers, or PBMs, for about a decade. The number of bills this session related to the PBM industry-about a third of all prescription drug legislation-is consistent with what NCSL has tracked on the topic since 2018.

Several states sought protections for independent pharmacies by steering contracts away from PBM-affiliated pharmacies, providing equal reimbursement to contract pharmacies and prohibiting increased audits, among other strategies.

For instance, Kentucky legislators passed a bill requiring network contracts between pharmacies and PBMs to include terms of reimbursement, which PBMs cannot then reduce. Instead of allowing PBMs to audit a network pharmacy at will, lawmakers in Louisiana gave authority to the insurance commissioner to develop rules under which a PBM can audit a pharmacy's records and claims.

A policy that has legislators on both sides of the aisle taking notice is white-bagging, when a PBM requires a health care provider to administer a drug shipped from a PBM-affiliated pharmacy instead of allowing the provider to buy the medication directly from the supplier and charge the patient's insurer. This can affect patients whose medications must be administered in a clinician's setting, for example, those receiving chemotherapy treatments for cancer. In Oregon, health plans and PBMs will no longer be able to limit or deny patients' coverage based on their choice of provider. Almost a dozen states have adopted similar white-bagging laws.

Idaho passed multifaceted legislation with provisions such as independent pharmacy protections and white-bagging restrictions, as well as requiring 100% of rebates paid by manufacturers to PBMs be passed through to plan sponsors to decrease premiums.

Similarly, health insurers and their contracted New Hampshire PBMs now must report how discounts and rebates were used to reduce costs for policyholders.

Looking Ahead

Except for the few states that remain in session year-round, the door on the 2024 legislative session has closed. Prescription drug access and affordability-already on the minds of voters and candidates as Election Day nears-will remain topics of discussion in state legislatures in 2025 and beyond.

Colleen Becker is a project manager in NCSL's Health Program.

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